YEFIRS Dan Vance 563 324 4120

Sep 27 05 09 :39a THE BEST

FOR INSTRUCTIONS, SEE BACK OF FORM FORM STATEMENT

OF
CHECK O DR-1
(Rev ORGANIZA7ION
an initial" Statement of Organization 0112003)
his is an amended" Statement of Organization For Office Use Only

'An initial Stafemcnl of Organization should be filled within 10 days of file commftree's accepting c~rltrb o»s. Comm . # _2 ,2_
making expenditures or incurring indebtedness exceeding S?S0 . Amendments s~o e,Gloif n'30 days o(a Indexed
otlange . Penalties may be imposed for !ate-filed Statements of Oroatil2ation Audited
Computer

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COMMITTEE NAME

I MPORTANT : Indicate type of committee you are reporting for:

( t )Statew(deluegislative Candidate (2 )Statewide PAC ( 3 )State Party (4 )County!Local Candidate ( 5 )County PAC ( t3 )Ballot IssuelFranchlse
Committee (7 )C ountyiCi ty Central Committee (8 )S upport sl a te of candidates (list candidates under purpose of committee)

COMMITTEE TREASURER COMMITTEE CHAIR

Na
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Name
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Y-1 6 15 S
Mailing Addrea3 Mailing Address

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Cdy~tato
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Zip Cod
d ~. _ice^
City, State
A/
Zip Code

Phone 314 7 Phone 1 (0 f

e-Mall o-Mall Aa-V iS`77 6-0-a-,0 ['Cow-

INDICATE PURPOSE OF COMMITTEE - Check One Box forlagansi candidates) C3 Advocate forlagainst ballot issuo(s)
Comment or description : Advocate
All Candidates Enter
Office Sought: . i A l',i` In tC~ District

Political Party (if applicable) Year Standing for Electinn _

County/Local Candidates and Local Ball ot/Franchlse Committees Enter.
County ,. Date of Election.

Bank account Nam e L 1 Candidate name $1 Address or Parent Entity (PACs, if aooj~able),
1 L. Affiliate, or Sponsor

CO
Name
M. ", i :11,
of Financial nstitutioNtype of Account 1 Mailing Address 1

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Maillng Address
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C d'td,,
City 1 1 State b t Zip

1-1L 0 ~A
sq,4'e+'v-~r
~l . 's 07 TO

T-7- State 1. 1 Zip

1 1 Phone ($631_ `?Q t6 - (n'4S--Q

e, iiev, sk . 5 a-7 a a._ -Mall 8a,ri vile 0 ale I , . . Co W.L.

DISPOSITION OF BHLANGt F FUNDS UPON DISSOLUTION (Slatoment of intent mquired by law for all committees, except state parlies and Central
Indicate dis,osillon of funds b marking appropriate number in box: 0 committees and comnUttoas usirg only personal funds.)
(1) DONATrO TO COUNTY CENTRAL COMMITI'EC (6) PRORATED REFUND TO CONTRIBUTORS
(2) DONArFn Tn LOCAUSTATE!NAT'L POLITICAL PASTY (vnUerl1n. ere) (7) TRANSFER Iii ANu I HtK CCMMITTEE OF THIS SAME CANDIDATE
(3) DONATED TO CHARITABLE ORGANIZATION (CANDIDATCS ONLY)
(spec9ty) (8) RETURN 1'0 PARENT ENTITY GENERAL FUND (PACE ONLY)
(a) CI I Y,000NTYiSCHOOLISTATE OF IDYVA GENERAL rUNO (underline one) (9) OTHER (PACs ONLY). PLEASE BE SPECIFIC
(5) PARTISAN CONGRESSIONAL DISTRICT FUND

STATEMENT OF AFFIRMATION BY TREASURER AND CANDIDATE; OR POLITICAL COMMITTEES, BY CHAIRPERSON

I am aware that I am required to file disclosure reports if the committee receives contributions, makes expenditures, or incurs indebtedness in excess of
$750,00 in a calendar year to expressly advocate for any candidate or ballot issue. I understand that although the treasurer normally prepares and files
reports . the canrliciaty or chairperson (PACs) ie reepor :;iblc under the law for accurate and littiely disclosure_ reports and that late-tiled reports are subject
to civil penalties and posslvle other legal action . I understand that by filing this form, I am subject to the laws found in Iowa Code chapter 56 . chapter 5, 813
and administrative Ivies found in chapter 351 1 affirm that all committee officers have been informed of their appointment and obligations

Signature of I asurer Signs

aL__ V 7; S~ s
Signature of Csndidata, OR, if PAC, Central Comrnition or Local BMW issue . Chairperson ale Signed